Does printing crisis line numbers help or harm?

Aug 27, 2015

I've reached the point in my suicide contagion project where new research is starting to fit very nicely into the final framework (which hopefully suggests I'm onto something, or alternatively that I've become blind to contrary information - either/or). Today I read some new research by Stack (2015) on if crisis phones on bridges were an effective means of suicide prevention.

What he found was a little unsettling. We know people use them (good!) and that these people tend not to jump (also good!) but did suicides on the bridge increase or decrease after their installation? They rose. Ah, but did the population increase? No. Did the local suicide rate increase as well? No it went down. Ah.

Stack draws attention to a blog that covers bridge suicides (as well as media coverage) that may be responsible in part for people choosing bridge suicide over another method. But he also notes (if we believe that 'suggestion' has influence on suicide) we should look carefully at those phones:

The suggestion thesis holds that the phones, which were installed with signs alerting suicidal people that they offer a link to help, will suggest suicide to vulnerable persons. These at-risk individuals may otherwise not have thought of suicide off the bridge (Beautrais, 2007; Glatt, 1987). The suggestion hypothesis assumes that such signs will affect only vulnerable persons at risk of suicide. It is unlikely that they would impact healthy person.

This last point is important - given we generally hold that at-risk people can be negatively affected by messaging we should consider this even when intentions are good.  Research on other public health interventions show we cannot rule out that things done in good faith to save lives will end up doing net harm.

Klimes-Dougan and Lee (2010) did a study on if suicide prevention billboards were effective - finding negative as well as positive effects. They found their billboard ("Prevent Suicide, Treat Depression – See your Doctor" ) was in general good at getting people to believe that treating depression was a good way to reduce suicide - but also that their high-risk group tended to end up with a stronger perceived link between depression and suicide after viewing a billboard. The worry here is that being too explicit about the connection to depressed people encourages a railroading of their future down that path. Their TV ad by contrast didn't have that effect - it used the phrase "it can even lead to suicide" as an escalation of symptoms of depression, making death one of several possible options.

The billboard group also ended up with lower help-seeking scores than the no-information group (A TV advert did better however, public health campaigns not completely doomed) - directly encouraging people to seek help might not have the results you hope for.

The lesson here is that this is tricky stuff - the words you use matter. A workshop on public messages for suicide prevention made the point that broad campaigns might be bad:

Broad-based campaigns that are likely to reach multiple audiences should determine how subgroups of intended populations (or nontargeted groups of a population) might have different attitudes about suicide, and may respond differently to messages geared towards increasing help-seeking behavior (Cauce et al. 2002).

But also that targeted campaigns might be bad:

For example, certain American Indian nations have very high rates of suicide. A campaign via popular Indian radio stations that highlights the high prevalence may inadvertently normalize suicide and send the message that such behaviour is expected and is inevitable. Groups with high rates may get the message that they have experienced an expected behaviour, and the groups with lower rates are simply "lagging behind" on what is seen to be inevitable.

You might say they're just being risk adverse - but we have to acknowledge that letting words loose into the world with the aim of saving lives is something we seem to know little about. As Beautrais, Fergusson, Coogan et al (2007) put it:

Until there is clear evidence that public health messages about suicide prevent, and do not normalize, suicide, and have no deleterious effects, the most prudent approach to this issue is not to include public health messages as part of a suicide prevention strategy.

This brings us to print crisis lines after newspaper articles in suicide - which are pretty clearly public health messages that are advocated frequently as part of a suicide prevention strategy.   Stack brings up Niederkrontenthaler et al (2010) who found that newspaper stories that printed the phone number of a crisis link seemed associated with an increase in suicide rates. Now for the record, the authors were more sceptical of this result than some of their others (they were checking for so many things and it was one of their least significant results - although still p < 0.05) - but I can't find anyone else who has suggested anything to the contrary. Others have done research on if suicide lines are effective on those they reach e.g Gould et al (2007) (answer: yes-ish - reduction in pain and hopelessness, but not an apparent reduction in intent to die), there seems to be very little work on if the advertisement of the lines is a good idea.

The problem here is the population who is exposed to the advertisement but who will not be exposed to any positive effect of the helpline - if this group contains at-risk individuals (which it does) then there is the prospect of harm. That printing a suicide number could be negative is consistent with research that billboards can have a harmful effect and the idea that crisis phones on bridges might not be universally fantastic.

That certain wordings of these crisis line adverts might be worse than others is consistent with the idea that suicide contagion is more powerful when people can identify (and have similarities) with the subject of the article. If the wording asks you if you identify ("If you're affected..." - "ooh, am I?") it might create or intensify a one-to-one relationship with the subject of the article upon introspection. This suggests that they shouldn't be viewed as a corrective or an addendum to the article but part of the text and so part of any journey of identification.

There clearly isn't enough evidence to say this is something papers should stop doing - but I think it's something we need to think more carefully about.  I find it worrying I can create a hypothesis based on the same theoretical framework the rest of contagion works on - and that's consistent with the evidence we do have - that says we are possibly making things worse.  Even if we take Niederkrontenthaler et al.'s scepticism seriously and move their result to the 'not proven' column it is deeply concerning that we have almost no positive evidence we can point to and say "printing the phone number makes the suicide rate go down" . The idea that the message can never have a negative effect on non-callers needs to have more thought put into it to justify the pre-eminence of this advice.

Stack's main point is that crisis phones are not a good substitute for barriers on bridges (just much cheaper). It's not clear what a more effective alternative to crisis line ads following suicide stories would be. I find the fact that most people who suffer from suicidal thoughts end up not taking their own life a reassuring idea - a disclaimer built around this idea encourages identification with the living rather than the dead (and creates a universe larger than the reader and the subject) could be an approach to explore. But there's no evidence on if this would be a good approach or not.

The final section of my project will deal more generally with how little evidence there is for a lot of suggested interventions - but I wanted to share a glimpse into just how much of an unknown doing anything 'positive' in this area can be.

Bibliography:

Stack, Steven. “Crisis Phones – Suicide Prevention Versus Suggestion/Contagion Effects.” Crisis, no. August (2015): 1–5. doi:10.1027/0227-5910/a000313.

Chambers, David A, Jane L Pearson, Keri Lubell, Susan Brandon, Kevin O Brien, and Janet Zinn. “The Science of Public Messages for Suicide Prevention : A Workshop Summary” 35, no. April (2005): 134–45.

Gould, Madelyn S, John Kalafat, Jimmie Lou Harrismunfakh, and Marjorie Kleinman. “An Evaluation of Crisis Hotline Outcomes Part 2 : Suicidal Callers” 37, no. June (2007): 338–52.

Klimes-Dougan, Bonnie, and Chih-Yuan Steven Lee. “Suicide Prevention Public Service Announcements: Perceptions of Young Adults.” Crisis 31, no. 5 (January 2010): 247–54. doi:10.1027/0227-5910/a000032.

Beautrais, A., Fergusson, D., Coggan, C., Collings, C., Doughty, C., Ellis, P., Hatcher, S. et al. (2007). Effective strategies for suicide prevention in New Zealand: A review of the evidence. The New Zealand Medical Journal, 120, 1–11.

For quoted sections:

Beautrais, A. (2007). Suicide by jumping: A review of research & prevention strategies. Crisis, 28 (Suppl. 1), 58–63.

Cauce, A.M., Domenech-Rodriguez, M, Paradise, M., Cochran, B.N., Shea, J. M., Srebnik, D,. et al. (2002) Cultural and contextual influences in mental health help seeking: A focus on ethnic minority youth. Journal of Consulting and Clinical Psychology, 70, 44-55

Glatt, K. M. (1987). Helpline: Suicide prevention at a suicide site. Suicide and Life-Threatening Behavior, 17, 299–309

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